Retraction of the century

Upper and lower eyelid retraction occurs in approximately 50% of patients with Graves disease. At the heart of the retraction are the following mechanisms.

1. Scarring contraction of the levator along with the development of adhesions with surrounding tissues of the orbit leads to retraction of the eyelid, which is especially pronounced when viewed from the bottom. Fibrous-altered lower rectus muscle can also lead to retraction of the lower eyelid.
2. The secondary increase in the tone of the levator-upper straight muscle complex due to the hypotrophy caused by fibrosis and rigidity of the lower rectus muscle is characterized by an increase in the retraction of the eyelid in the translation of the gaze from the bottom up. Retraction of the lower eyelid as a result of the increased tone of the lower rectus muscle can also be secondary in nature and is caused by fibrosis of the superior rectus muscle.
3. The humorally conditioned increased muscle tone of Muller appears as a result of excessive sympathetic stimulation by thyroid hormones. In favor of this hypothesis is evidence of a decrease in retractions of the eyelid with topical application of sympatholytics (guaetidine), and against - the absence of associated dilatation of the pupil and the occurrence of retraction without hyperthyroidism.

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Symptoms of retraction of the eyelid

The margin of the upper eyelid is normally located 2 mm below the limb. The retraction of the century can be suspected if the edge of the century is at or above the upper limb, revealing a scleral band (scleral outcrop). The lower eyelid is located at the level of the lower limb; when the sclera is exposed under the limb, one can think of the retraction of the century. The retraction of the eyelid can be isolated or in combination with exophthalmos, which aggravates the condition.

1. The symptom of Dalrymple is the retraction of the eyelid in the usual direction of the gaze.
2. The symptom of von Graefe is the lag of the upper eyelid from the eye when looking down.
3. The Kocher symptom is a bewildered and frightened look, especially when carefully considering something.

Treatment of retraction of the eyelid

Easy retraction of the eyelid does not require treatment, as spontaneous improvement often occurs. Efforts should be focused on controlling hyperthyroidism. Surgery aimed at reducing the size of the ocular gap can be considered in cases of pronounced but stable retraction of the eyelid and only after treatment of exophthalmos and strabismus. The sequence in the surgical treatment of endocrine ophthalmopathy is as follows: orbit, strabismus, eyelid. The expediency of such a sequence is that, like decomposition of the orbit, it can affect the mobility of muscles and the position of the eyelid, just as an operation on the extraocular muscle can change the position of the eyelid. The main types of operations are as follows:

1. Recession of the lower rectus muscle, when its significant fibrosis is assumed.
2. Mullerotomy (clipping of the muscle of Muller) with easy retraction of the eyelid. In more severe cases, the recession of the aponeurosis of the levator and the ligament supporting the upper conjunctival arch is shown.
3. Recession of the retractors of the lower eyelid by a scleral flap with the eyelid drooping 2 mm or more.